Endoscopic therapy for severe ulcer bleeding

Upper gastrointestinal (UGI) bleeding secondary to ulcer disease occurs commonly and results in significant patient morbidity and medical expense. After initial resuscitation, carefully performed endoscopy provides an accurate diagnosis of the source of the UGI hemorrhage and can reliably identify those high-risk subgroups that may benefit most from endoscopic hemostasis. Effective endoscopic hemostasis of ulcer bleeding can significantly improve outcomes by reducing rebleeding, transfusion requirement, and need for surgery, as well as reduce the cost of medical care. This article discusses the important aspects of the diagnosis and treatment of bleeding from ulcers, with a focus on endoscopic therapy.     

Management of non-variceal upper gastrointestinal bleeding

Upper gastrointestinal bleeding (UGIB) is a critical condition that demands a quick and effective medical management. Non-variceal UGIB, especially peptic ulcer bleeding is the most significant cause. Appropriate assessment and treatment have a major influence on the prognosis of patients with UGIB. Initial fluids resuscitation and/or transfusion of red blood cells are necessary in patients with clinical evidence of intravascular volume depletion. Endoscopy is essential for diagnosis and treatment of UGIB, and should be provided within 24 hours after presentation of UGIB. Pre-endoscopic use of intravenous proton pump inhibitor (PPI) can downstage endoscopic signs of hemorrhage. Post-endoscopic use of high-dose intravenous PPI can reduce the risk of rebleeding and further interventions such as repeated endoscopy and surgery. Eradication of Helicobacter pylori and withdrawal of non-steroidal anti-inflammatory drugs are recommended to prevent recurrent bleeding.     

Enseignement de la prise en charge endoscopique des hémorragies digestives

Gastrointestinal bleeding is an unprevisible and serious event requiring urgent management. Endoscopic hemostasis is defined by the cessation of bleeding and prevention of rebleeding by applying one or more technical endoscopic hemostatic techniques. It is an advanced procedure. Training in endoscopic hemostasis is difficult partly due to the urgent and unpredictable condition of gastrointestinal bleeding. Training by tutoring only (performing clinical cases under the supervision of a trainee) is long and difficult because it depends on the clinical cases seen during fellowship. Endoscopic management of GI hemorrhage includes important knowledge in medical management, in systematic categorization of both source of bleeding and the technique used to control it, and basic knowledge about technical skills to perform endoscopic procedure. Various simulation platforms, including virtual reality simulators, and animal models are available and efficient for training in endoscopic hemostasis. However, validated criteria for obtaining and maintaining procedural competence in endoscopic hemostasis techniques are still lacking.     

Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding

Background

Several risk score systems are designed for triage patients with acute nonvariceal upper gastrointestinal bleeding (UGIB). Blatchford score, which relies on only clinical and laboratory data, is used to identify patients with acute UGIB who need clinical intervention (before endoscopy). Clinical Rockall score, which relies on only clinical variables, is used to identify patients with acute UGIB who have adverse outcome, such as death or recurrent bleeding. Complete Rockall score, which relies on clinical and endoscopic variables, is also used to identify patients with acute UGIB who died or have recurrent bleeding. In our study, we define patients who need clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control) as high-risk patients. Our study aims to compare Blatchford score with clinical Rockall score and complete Rockall score in their utilities in identifying high-risk cases in patients with acute nonvariceal UGIB.

Methods

International Classification of Diseases, Ninth Revision, Clinical Modification codes for admission diagnosis were used to recognize a cohort of patients (N = 354) with acute UGIB admitted to a tertiary care, university-affiliated hospital. Medical record data were abstracted by 1 research assistant blinded to the study purpose. Blatchford and Rockall scores were calculated for each enrolled patient. High risk was defined as a Blatchford score of greater than 0, a clinical Rockall score of greater than 0, and a complete Rockall score of greater than 2. Patients were defined as needing clinical intervention if they had a blood transfusion or any operative or endoscopic intervention to control their bleeding. Such patients were defined as high-risk patients.

Results

The Blatchford score identified 326 (92.1%) of the 354 patients as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control). The clinical Rockall score identified 289 (81.6%) of the 354 patients as high-risk, and the complete Rockall score identified 248 (70.1%) of the 354 patients as high-risk. The yield of identifying high-risk cases with the Blatchford score was significantly greater than with the clinical Rockall score (P < .0001) or with the complete Rockall score (P < .0001).In our total 354 patients, 246 (69.5%) patients were categorized as those with high risk for clinical intervention (ie, blood transfusion, endoscopic or surgical management for bleeding control, as aforementioned) in our study. The Blatchford score identified 245 (99.6%) of 246 patients as high-risk. Only 1 patient who met the study definition of needing clinical intervention was not identified via Blatchford score. This patient did not have recurrent bleeding nor die and did not receive blood transfusion. The clinical Rockall score identified 222 (90.2%) of 246 patients as high-risk. Twenty-four patients who met the study definition of needing clinical intervention were not recognized via clinical Rockall score. Of these patients, 0 died, 7 developed recurrent bleeding, and 6 needed blood transfusion. The complete Rockall score identified 224 (91.1%) of 246 patients as high-risk. Twenty-two patients who met the study definition of needing clinical intervention were not recognized via complete Rockall score. Of these patients, 2 died, 3 developed recurrent bleeding, and 20 needed blood transfusion.

Conclusions

The Blatchford score, which is based on clinical and laboratory variables, may be a useful risk stratification tool in detecting which patients need clinical intervention in patients with acute nonvariceal UGIB. It does not need urgent endoscopy for scoring and has higher sensitivity than the clinical Rockall score and the complete Rockall score in identifying high-risk patients.     

上消化道出血与非甾体类抗炎药物的关系

目的:探讨非甾体抗炎药(NSAIDs)诱发上消化道出血(uppergastrointestinalbleeding,UGIB)的临床流行病学特点。方法:调查中山大学附属第二医院及广东省台山市人民医院2000年1月～2006年10月间因上消化道出血收住院治疗患者的临床资料,根据入院前1周内有无服用NSAIDs史将患者分为2组,对2组病人的临床资料进行分析比较。结果:本研究共纳入366例患者,其中服药组103例,未服药组263例。2组病人在性别、出血方式、胃及十二指肠病变的具体部位以及是否需要内镜治疗等方面的差异无显著性;服药组患者的年龄较未服药组更高,血红蛋白在服药组下降更明显(P<0.01);胃溃疡和复合溃疡、多发溃疡在服药组更多见(P<0.01),而未服药组幽门螺杆菌(Hp)的感染率与服药组的感染率有显著差异,分别为26.24%和65.05%(P<0.05)。进一步的研究发现,患者年龄和Hp感染状态和上消化道出血史对NSAIDs相关的上消化道出血的临床特点有明显影响。结论:应加强对NSAIDs相关性上消化道出血临床特点的认识,尽量减少NSAIDs的不良反应。     

Basic requirements of gastroenterologists to treat upper gastrointestinal bleeding: competency and sedation issues

This article reviews the components of adequate training required for a gastroenterologist to treat upper gastrointestinal bleeding (UGIB). The current status of endoscopic simulators is critically reviewed to determine whether these should be part of the UGIB armamentarium in the training of individuals and whether credentialing could be accomplished through this method of instruction. Finally, the author discusses the appropriate use of sedation in patients with UGIB.     

内镜下金属钛夹止血联合黏膜下注射肾上腺素治疗溃疡性上消化道出血的效果及对氧化应激指标的影响

目的探讨内镜下金属钛夹止血联合黏膜下注射肾上腺素治疗溃疡性上消化道出血(UGIB)的效果及对氧化应激指标的影响。方法将2016年5月至2020年5月住院治疗的86例溃疡性UGIB患者按随机抽签法分为对照组与观察组,每组43例。对照组于内镜下黏膜下注射肾上腺素,观察组在对照组基础上联合内镜下金属钛夹止血,比较两组的治疗效果。结果观察组的治疗总有效率高于对照组(P<0.05)。观察组的止血时间、大便潜血转阴时间、住院时间短于对照组(P<0.05)。治疗后,观察组的AOPP、MDA、血管升压素水平低于对照组(P<0.05)。观察组的不良反应总发生率低于对照组(P<0.05)。结论内镜下金属钛夹止血联合黏膜下注射肾上腺素治疗溃疡性UGIB可获得理想的止血效果,缩短止血时间,改善患者氧化应激指标,安全可靠。     

Épidémiologie des hémorragies digestives hautes en Tunisie

Background

Acute upper gastrointestinal bleeding (UGIB) continues to be a common cause of hospital admission and morbidity and mortality. Epidemiological studies are still limited in our country.

Aim and objectives

The aim of this study is to determine the causes and outcome of patients with UGIB presenting at the teaching hospital of Monastir.

Materials and methods

The study was carried out at the teaching hospital of Monastir. The records of 874 patients who underwent endoscopy for UGIB over a period of 10 years (1997–2007) were retrospectively analysed.

Results

The acute UGIB represented 5.3% of all high digestive endoscopy. Male predominance (63.1%) was noted with an average age of 54 ± 12 years. A bleeding site could be detected in 75.6% of the patients. Diagnostic accuracy was greater within the first 24 hours of the bleeding onset and in the presence of hematemesis. Peptic ulcer was the main cause of UGIB (50.5%) followed by erosive mucosal disease (24%). The prevalence of variceal bleeding was 9.49%. Endoscopic treatment was used in 103 cases (11.7%). Operations were performed in 51 cases (9.9%), including 9.9% of ulcers. There were 36 deaths (4.1%).

Conclusion

Peptic ulcer was the most common cause of gastrointestinal bleeding in our country. Mortalitywas raised in variceal group. Most cases of UGIB can be treated with endoscopic hemostasis, when diagnostic endoscopy establishes the source.     

微孔多聚糖止血材料在消化性溃疡出血内镜治疗中的疗效及安全性观察

目的 探讨微孔多聚糖止血材料在消化性溃疡出血内镜治疗中的疗效及安全性。方法 收集内镜下诊断为消化性溃疡伴出血患者25例（观察组）,内镜下止血治疗方法为常规止血方法（机械止血、电凝止血）联合微孔多聚糖止血材料进行电动正压喷洒止血治疗,对比同期采用常规止血方法治疗的消化性溃疡伴出血患者25例（对照组）,比较2组患者5min...     

Acute upper gastrointestinal bleeding: comparison between recent users and nonusers of nonsteroidal anti-inflammatory drugs

BACKGROUND AND STUDY AIMS: To determine clinical, endoscopic, and outcome differences between recent users and nonusers of nonsteroidal anti-inflammatory drugs (NSAIDs) presenting with upper gastrointestinal bleeding (UGIB). PATIENTS AND METHODS: A total of 330 consecutive patients who presented with clinical manifestations of UGIB underwent urgent endoscopy after clinical assessment within 12 h of admission. The patients were divided into two groups, depending on whether there was a positive or negative history of recent NSAID use. Urgent endoscopy followed by endoscopic hemostasis and/or biopsy, as needed, was performed by the same endoscopist, who was blinded to the patients' clinical status. RESULTS: The baseline characteristics, clinically estimated severity of UGIB, and outcome did not differ between the two groups. Recent NSAID users were found to bleed from an ulcer more frequently (P=0.009) than nonusers of NSAIDs, the latter more often having a history of peptic ulcer or UGIB (P=0.02). Bleeding ulcers were mostly duodenal in the NSAID group and gastric in the non-NSAID group (P<0.001). Helicobacter pylori infection was significantly more common among NSAID users (P<0.01). The group of NSAID users included a significantly greater proportion of alcohol abusers (P=0.01), who were found to bleed mostly from erosive gastritis. CONCLUSIONS: Recent NSAID users were found to bleed from ulcers, mostly duodenal, and to have H. pylori infection more frequently than UGI bleeders with a negative history of NSAID consumption. Alcohol abuse was also more common among NSAID users. The severity of bleeding and the outcome did not differ between the two groups.     

Differential diagnosis of upper gastrointestinal bleeding proximal to the ligament of Trietz

Upper gastrointestinal bleeding (UGIB) is an important medical problem for patients and the medical system. The causes of UGIB are varied and their accurate identification guides appropriate management. The major cause of UGIB is peptic ulcer disease, for which Helicobacter pylori and nonsteroidal antiinflammatory drug use are major risk factors. Lesser causes include Dieulafoy lesion, gastric antral vascular ectasia, hemobilia, aortoenteric fistulas, and upper gastrointestinal tumors. Awareness of causes and management of UGIB should allow physicians to treat their patients more effectively.     

内镜注射在治疗Dieulafoy病活动性出血的应用

目的观察内镜下黏膜内注射硬化剂治疗Dieulafoy病活动性出血的治疗效果。方法经胃镜检查而确诊的Dieulafoy病合并活动性出血的病人23例，在内镜下用注射针经内镜活检孔至出血部位，在出血部位周围1，2mm处注射3～5点，每点5为5．00％鱼肝油酸钠或1．00％乙氧硬化醇0．5～1．0ml，其中用5．00％鱼肝油酸钠11例，1．00％乙氧硬化醇12例。结果止血成功率达95．65％(22／23)。需要第二次内镜治疗成功者3例(0．13％)治疗失败者1例(占0．04％)。结论内镜下注射治疗可作为Dieulafoy病活动性出血的首选治疗方法之一进行推广应用。     

前列腺汽化电切术后大出血的预防与处理

目的探讨经尿道前列腺汽化电切术(TUVP)后大出血的预防与处理。方法对TUVP术后大出血患者行保守治疗、电切镜下止血或手术止血。结果310例行TUVP术患者中，12例发生术后大出血．出血发生于术后1～25d，多发生于2、3周。经保守治疗止血6例，经电切镜止血5例，经开放手术止血1例。结论术前充分做好准备，术中止血确切，术后保持引流通畅，避免创面感染及受压是预防TUVP术后大出血的关键。及时发现并处理前列腺术后出血，多可行保守治疗，避免再次手术。电切镜下止血是一种安全而有效的治疗方法，术后出血较多，经保守治疗及电切镜下止血无效时应及时转开放手术。     

The usefulness of endoscopic hemoclipping for bleeding Dieulafoy lesions

BACKGROUND AND STUDY AIMS: Dieulafoy lesion is a rare cause of massive gastrointestinal hemorrhage, most commonly from the proximal stomach. Surgery was regarded as the treatment of choice in the past, but recently endoscopic management has become the standard approach. However, the effectiveness of various endoscopic modalities in treating bleeding Dieulafoy lesion has been little studied. This study was therefore done to compare the hemostatic efficacy of endoscopic hemoclipping and epinephrine injection therapy. PATIENTS AND METHODS: Between January 1998 and December 2001, a consecutive series of 32 patients with bleeding Dieulafoy lesion underwent endoscopic treatment. They were randomly treated either by endoscopic epinephrine injection therapy (n = 16) or by hemoclipping (n = 16). We compared mortality rate, primary hemostasis rate, and rebleeding rate between two groups. RESULTS: There was no bleeding-related death in either group. There was no significant difference in primary hemostasis rates between the hemoclipping group (93.8 %) and epinephrine injection group (87.5 %, P = 1.00). There was a trend toward a lower rate of need for multiple endoscopic sessions to achieve permanent hemostasis in the hemoclipping group compared with the epinephrine injection group (6.3 % vs. 31.3 %, P = 0.086). Hemoclipping was significantly more effective in preventing recurrent bleeding than epinephrine injection therapy (0 % vs. 35.7 %, P < 0.05). With regard to lesion site, hemoclipping was significantly more effective in preventing recurrent bleeding of gastric body Dieulafoy lesion than epinephrine injection therapy (0 % vs. 50 %, P < 0.05). CONCLUSIONS: Bleeding from Dieulafoy lesion was well controlled by therapeutic endoscopic procedures. Hemoclipping was more effective for Dieulafoy lesion than epinephrine injection therapy, with less need for subsequent endoscopy.     

老年人上消化道出血与长期服用小剂量阿司匹林的关系

目的　观察长期服用小剂量阿司匹林老年人上消化道出血的发生情况及影响因素。方法　 5 6例服用小剂量阿司匹林老年人 ,根据胃镜检查前一周内有无上消化道出血将其分为出血组与非出血组 ,胃镜观察其胃、十二指肠黏膜损伤情况 ,快速尿素酶试验和改良Giesma染色方法检测幽门螺杆菌 ,分析其上消化道出血的有关影响因素。结果　 5 6例老年人中发生上消化道出血 17例 ,发生率 30 4 % ,出血组胃黏膜损伤积分、幽门螺杆菌 (Hp)感染率均明显高于非出血组 (P <0 0 1)。多因素分析表明 ,Hp感染、既往出血病史及年龄可增加上消化道出血的危险性 ,而用药时间与上消化道出血无相关性。结论　长期小剂量服用阿司匹林可增加老年人上消化道出血的危险性 ,其发生与Hp感染、既往出血病史及年龄有关     

Risks related with withholding and resuming anticoagulation in patients with non-variceal upper gastrointestinal bleeding while on warfarin therapy

Background: The use of warfarin is growing for the prevention or treatment of cardiovascular or cerebrovascular diseases. The risk of haemorrhagic side effects is increased in patients taking warfarin. Aims: To evaluate risks related with withholding and resuming anticoagulation in patients with upper gastrointestinal bleeding (UGIB) while on warfarin therapy and the role of the second‐look endoscopic examination (SEE). Methods: Records of 58 patients with native valvular heart diseases who presented with non‐variceal UGIB during chronic anticoagulation with warfarin were retrospectively reviewed. Age‐ and gender‐matched patients with non‐variceal UGIB during aspirin therapy because of ischaemic heart disease were recruited as the control group. Results: Development of both recurrent bleeding and thromboembolic events were more frequent in warfarin group than in control group (7.0% vs. 0% with p = 0.03 and 16.7% vs. 2.4% with p < 0.01, respectively). One of four cases of recurrent bleeding in warfarin group was found by SEE performed in an asymptomatic patient. There were six thromboembolic events which occurred on the 21st, 27th, 28th, 31st, 58th and 75th day from the presentation out of 36 patients who ceased anticoagulation. In contrast, only one from 41 in whom aspirin was discontinued experienced myocardial infarction. There was no difference in the failure of endoscopic haemostasis necessitating angiographic embolisation or surgery, hospital stay, the need of transfusion and overall mortality. Conclusions: Anticoagulation is recommended to be resumed before the 20th day from the cessation to prevent thromboembolic events. A routine SEE before resuming anticoagulation might be helpful to detect asymptomatic recurrent bleeding.     

内镜止血夹治疗急性上消化道大出血的临床研究

目的：检验内镜止血夹对急性上消化道大出血的止血疗效，并初步探讨其影响疗效的相关因素，方法：采用Olympus SHX-5LR-1止血夹置放器和MD850内镜止血夹，止血夹以直角夹闭出血病灶，结果：18例急性上消化道大出血均获得即时止血，无1例发生再出血和并发症，结论：内镜止血夹为急性上消化道大出血提供了一种损伤小，止血成功率和安全性高的治疗方法。     

Evaluation of endoscopic hemostasis in upper gastrointestinal bleeding related to Mallory-Weiss syndrome

BACKGROUND AND STUDY AIMS: The endoscopic hemostatic method has been introduced as a safe and effective mechanical approach to hemostasis for upper gastrointestinal bleeding related to Mallory-Weiss syndrome (MWS). However, the indications for when to use endoscopic treatment are debatable because many patients need only medical observation. The study was designed to evaluate the necessity and efficacy of endoscopic hemostasis in upper gastrointestinal bleeding related to MWS. PATIENTS AND METHODS: From July 1994 to May 2000, we conducted a clinical trial in 76 patients who were found by endoscopy to have active bleeding (I, spurting; II, oozing), protruding visible vessels (III), and/or adherent clots (IV). Two study periods can be differentiated: in the first 3 years endoscopic treatment (n = 30) was prospectively analyzed and in the final 3 years medical treatment (n = 46) was analyzed in both cases to compare the outcome in MWS bleeding II-IV. In the first study period, in addition, endoscopic treatment was randomised to an injection method, using a mixture of hypertonic saline and epinephrine (HSE) (n = 14) and a hemoclipping or band ligation method (n = 16). RESULTS: Rebleeding was observed in four of 14 patients who had received endoscopic hemostasis with HSE injection and one of 46 patients who had been managed with medical treatment. No rebleeding was found following hemoclipping or band ligation. While all rebleeding was in bleeding stigmata of the I (1) and II (4) grades, there was no rebleeding in protruding visible vessels (III) or in adherent clots (IV), regardless of treatment methods. CONCLUSIONS: Our results suggested that endoscopic hemostasis is not necessary in patients without active bleeding stigmata, and the mechanical hemostatic method is more effective than HSE injection in patients with active bleeding stigmata.     

Endoscopic hemostasis using covered metallic stent placement for uncontrolled post-endoscopic sphincterotomy bleeding

Severe bleeding following endoscopic biliary sphincterotomy (EBS) can sometimes be difficult to manage, resulting in the need for an invasive intervention. The aim of this study was to retrospectively evaluate the feasibility and efficacy of endoscopic hemostasis using covered self-expandable metallic stents (SEMSs) for severe post- EBS bleeding. Eleven patients with bile duct stones underwent standard EBS using a standard sphincterotome-based technique at 4 endoscopic units of a university-affiliated hospital and a general hospital. Monotherapy or combined therapy were used to achieve hemostasis with either balloon tamponade, hypertonic saline epinephrine injection, or endoclip placement. When active bleeding could not be controlled, covered SEMSs were placed across the major papilla. Emergency endoscopy was performed on the day of admission or the subsequent day (ranging from 6 to 35 h after admission). Bleeding was classified as mild in 6 cases (54.5 %) and moderate in 5 (45.5 %). A covered SEMS 10mm in diameter and 6 cm long was placed across the papilla. After placement, complete hemostasis was achieved. The mean duration of stent placement was 8.2 days (range 5–10 days), and the SEMS was successfully removed in all cases. Although the present study has the limitations of a small sample size and lack of control patients, covered SEMS placement for endoscopic hemostasis may be useful in selected patients with uncontrolled post-EBS bleeding.     

Cholecystoduodenal fistula presenting with upper gastrointestinal bleeding: A case report

BACKGROUNDCholecystoduodenal fistula is a rare complication of cholelithiasis. Symptoms are usually non-specific and often indistinguishable from those of etiologic diseases, but it rarely presents as severe gastrointestinal bleeding. Bleeding associated with cholecystoduodenal fistula usually requires surgery because significant bleeding from the cystic artery is unlikely to be resolved by conservative management or endoscopic hemostasis.CASE SUMMARYWe report a case of cholecystoduodenal fistula that presented with hematemesis which was diagnosed by endoscopy and computed tomography. Endoscopic hemostasis could not be achieved, but surgical treatment was successful. Additionally, we have presented a literature review.CONCLUSIONCholecystoduodenal fistula should be considered as differential diagnosis when a patient with history of gallstone disease presents with gastrointestinal bleeding.